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Saturday, November 30, 2013

Robert Lustig’s UCTV YouTube video
sensation, “Sugar, the
Bitter Truth,”
has been seen almost 4 million times. Recently, the UCSF pediatric
endocrinologist made a sequel, “Fat Chance: Fructose 2.0,” that will
also go viral. It’s 86 minutes long, so you’ll need to set aside a block of
time to watch it, but it’s worth it. Here’s a 45 second excerpt I transcribed (starting
at +/-12:00) that fits in with a theme I’ve been beating the drum about since
The Nutrition Debate #9, “The Metabolic
Syndrome,”
published almost 3 years ago.

Lustig: “Obesity is not the problem.
It never was. They want you to think it’s the problem, but it ain’t the
problem. What is the problem? Metabolic Syndrome is the problem. The cluster of
diseases that I’ve described to you. That’s where all the money goes. Obesity
costs almost nothing. Metabolic Syndrome is 75% of all health care costs today.
And there’s the list right there. [Slide lists: DIABETES, HYPERTENSION, LIPID
ABNORMALITIES, CARDIOVASCULAR DISEASE, NON-ALCOHOLIC FATTY LIVER DISEASE,
POLYCYSTIC OVARIAN DISEASE, CANCER, DEMENTIA] Everybody with me now? Do I have
your attention?”

A
brief recap – What is Metabolic Syndrome”? And how is it diagnosed? Definitions
vary but most have five “risk factors” in common, with the first always being obesity.
It is variously defined as “central
obesity,” or what I have coined “omental adiposity”, or a Body Mass Index
(BMI) ≥30, or elevated waist circumference (men ≥40 inches, women ≥35 inches).
The other four “risk factors” are elevated
triglycerides (≥150mg/dl), reduced
HDL, the “good” cholesterol (men ≤40mg/dl, women ≤50mg/dl), elevated blood pressure (≥130/85mm Hg,
or use of medications for hypertension) and elevated fasting glucose (≥100 mg/dl, or use of medications for
hyperglycemia). If you “present” with 4 out of 5, you have Metabolic Syndrome.
Do I have your attention?

The corollary to “obesity is not the
problem” is equally riveting: “everyone’s
at risk,” as Lustig explains: “Everyone’s at risk, because everyone is exposed.” That, of course, begs the question: exposed
to what?

Dr. Lustig precedes his “obesity is
not the problem” mantra with a nice explanation of the implications of the
difference between subcutaneous fat (fat near the surface of the skin) and
visceral fat (fat around the abdominal organs).The latter is the “bad” type of
obesity. He starts with a diagram showing 30% obese and 70% “normal” weight,
“and everybody assumes that the problem is this group over here [the 30% obese]
because 80% of the obese population is sick in some fashion: type 2 diabetes
problems, lipid problems, hypertension, cardiovascular disease, cancer,
dementia, non-alcoholic fatty liver disease, polycystic ovarian disease, etc.”

“But,” he continues, “you do the math
on this, 80% of 30% [of the 240 million adult population] is 57 million, and it
is those 57 million that are bankrupting the country, so it’s the obese
person’s fault only, and that’s the way everyone views this. This is wrong.
This is a mistake. This is a disaster, actually, ‘cause it’s not correct.
Here’s the real story. In fact, 20% of the obese population is completely
metabolically normal. They have normal insulin dynamics. They don’t get sick.
They live a completely normal life, die at a completely normal age, cost the
taxpayer nothing. They’re just fat.”

“Conversely, up to 40% of the “normal”
weight population has the exact same metabolic dysfunction that the obese do. They’re
just normal weight, and so they don’t even know they’re sick until it’s too late;
because normal weight people get type 2 diabetes, they get hypertension, they
get dyslipidemia, they get cardiovascular disease, they get cancer, they get
dementia, etc. etc. And so, when you do the math on that, that’s another 67
million, and so that’s actually outclassing the 57 million obese, and so the
total is 124 million; that’s more than half [the adult population] of America.”

So, that’s why Dr. Lustig says,
“Everyone’s at risk, because everyone is exposed.” Exposed to what, you ask? Metabolic Syndrome! And how do you
treat Metabolic Syndrome? Answer: you “treat” the risk factors: 1) central
obesity, 2) elevated triglycerides, 3) reduced HDL, 4) elevated blood pressure,
and 5) elevated fasting glucose. And what treatment, pray tell, addresses all
five risk factors for Metabolic Syndrome? In case you haven’t figured it out
yet, the answer is a Low Carbohydrate Way of Eating. No pills, no injections,
no surgery. Just a different way of eating.

Okay, you say, I can see how a low-carb
Way of Eating can help me lose weight and control my blood glucose. And I can
see that as I lose weight (as almost everyone wants to do anyway), how my blood
pressure will go down. (Mine did, from 130/90 to 110/70 on the same meds.) And
maybe I can believe that by eating low-carb, I can lose weight without hunger
and without snacks, and even
keep the weight off, so long as I
continue to eat low-carb. But how can I expect that eating low-carb
will cause my elevated triglycerides to go down and my HDL to go up? Well, mine
did, dramatically: My HDL doubled from
39 to 81, and my
triglycerides
dropped by about two-thirds, from 137 to 49, just by eating very low carb.
Scientifically, an n = 1 means nothing, unless
that n = 1 is you! PS: Here’s another
interesting n = 1 on Low Carb
Lowers Triglycerides
from Dr. Art Ayers’s blog.

Wednesday, November 27, 2013

As
a long time (27 year) type 2 diabetic who has pretty much controlled the
disease (and gotten off 3 classes of oral diabetes meds) by diet alone for the
last 11 years, I have long argued that snacks are unnecessary. If you haven’t
eaten a Very Low Carb (VLC) breakfast and a no-carb lunch every day, as I do,
you may doubt this. You may even say it is not credible. But as incredible as it sounds, it is absolutely
true. You have to try this VLC Way of Eating (WOE) to discover this for
yourself. You will not be
hungry between meals.

I admit to snacking sometimes, either before
dinner (radishes or celery usually, sometimes
with salt and a little butter or a little whipped cream cheese, respectively),
and occasionally after dinner (a
controlled portion of nuts). Why? Not because of physical hunger or any other known
nutritional need. I describe it as nervous eating, and I always ask myself if I
am hungry before I do it, and I always answer “no;” then, I do it anyway. Go
figure!

So, when I saw a link to David Mendoza’s
column
in the Low Carb Diet News titled,
“The Best Snack for Weight Loss and Diabetes, I was interested. Mendoza is a
well-respected and well read blogger (well-read in both senses) who describes
himself as a “freelance medical writer, advocate, and consultant specializing
in diabetes.” He has been a type 2 diabetic since 1994 and he started writing about
it online in 1995. So, David Mendoza has credibility.

But after I read through his piece
about the “best snack,” I felt his credibility was somewhat tarnished, as I’ll
explain shortly. First, I want to point out some of the good stuff. Early on in
his blog piece he emphasizes this:

“Unlike
some other tasty nuts like cashews, almonds are much lower in carbohydrates,
which are the part of our diet that is almost solely responsible for raising
our blood sugar level. Nothing else in our diet is more important for managing
our diabetes than keeping that level in check.”

His point about cashews and carbs is
good. Cashews and pistachios (drats; I love them.) are both too high in carbs
to be considered as part of a healthy diet for type 2 diabetics. I address this
in my column
about nuts.

“Some
other nuts have a somewhat more favorable ratio of those super-healthy
monounsaturated to polyunsaturated fats than almonds. But I avoid them as a
matter of taste. I can eat macadamia nuts nonstop until the container is empty,
but my body gets so full that I can easily put on a few pounds. On the other
hand, I don’t particularly appreciate the taste of other healthy nuts like
pecans or walnuts.”

I
certainly agree with his point about macadamia nuts. They’re also very
expensive. (Does anybody know a source for buying macadamia nuts wholesale?)
However, as I mention in my column, for me the only basis for selecting which type
of nuts to eat (besides carbs) is their Omega 6 content. In that respect, I
disagree with Mendoza. Pecans are marginal at best and walnuts are totally verboten. The very best, excluding again
cashews and pistachios because of the carbs, are macadamia nuts, hazelnuts
(filberts), and then almonds.

Now, to the problem: It turns out “the
best snack for weight loss and diabetes” is almonds. And although Mendoza
expresses a personal preference for raw almonds (which he keeps in the freezer
to give them a little “crunch”), the study he cites is with roasted and salted
almonds. The study, however, as Mendoza points out, seems to have a fatal flaw:
it was funded by the Almond Board of California. Oh dear…

“A
few days ago the European Journal of Clinical Nutrition published the study
online in advance of printing it. The abstract of “Appetitive, dietary and
health effects of almonds consumed with meals or as snacks: a randomized,
controlled trial,” is available at the journal’s
website.”

In the positive, Mendoza says, “A big
strength of this study by Purdue University and Australian researchers is that
it was randomized and controlled. This is a good sized study conducted with the
standard controls.”

In the negative, Mendoza states that
he sees 3 problems with the study: 1) he cites the funding source, “…although
they [the authors] also report that they have no conflicts of interest;” 2) “…
we still don’t know why the study participants who snacked on almonds didn’t
gain weight.” (For an explanation, check this out); and 3) “…this was also a
short study that couldn’t measure the long-term impact of snacking on almonds.”

These are all good points. I’m only
disappointed that I had to read to the end to learn that the almond study’s
authors, and David Mendoza’s recommendation, were flawed by the study’s
inherent conflict of interest. Almonds could be my favorite snack too, but bear
in mind that the study’s snack size, 1½ ounces (20 almonds) is 250 calories!
That’s half a dinner-time meal (for me). How can anyone hope to lose weight
eating a 250 calorie snack on a regular basis?

Saturday, November 23, 2013

The lede in a recent
piece on USAToday
sets the stage: “Higher blood sugar levels, even those well short of diabetes,
seem to raise the risk of developing dementia,
a major new study finds. Researchers say it suggests a novel way to try to
prevent Alzheimer’s disease -- by keeping glucose at a healthy level.” The
article was based on a study at the University of Washington, Seattle, and was published
in the New England Journal of Medicine.

A piece by Megan Brooks in
MedScape Medical News quotes the
study’s lead author, Dr. Paul Crane, as saying, “We considered blood glucose
levels far into the normal (nondiabetic) range, and even there found an
association between higher glucose levels and dementia risk.” “He said the
results suggest that the ‘clinical determination of diabetes/not diabetes may
miss important associations still there for people who are categorized as not
having diabetes’.”

The Associated Press story on the USAToday piece was written by Marilynn
Marchione. She quotes Dallas Anderson, a scientist at the National Institute on
Aging, the federal agency that paid for the study: “It’s a nice clean pattern
-- risk rises as blood sugar does.” According to Marchione, Anderson said, “This
is part of a larger picture” and adds evidence that exercising and controlling
blood pressure, blood sugar and cholesterol are a viable way to delay or
prevent dementia.

Marchione then also quotes Dr. Crane,
“At least for diabetics, the results suggest that good blood-sugar control is
important for cognition.” And, for those without diabetes, he said, “it may be
that with the brain, every additional bit of blood sugar that you have is
associated with higher risk. It changes how we think about thresholds, how we
think about what is normal, what is abnormal.”

Charles Bankhead of The Gupta Guide at
MedPageToday commented, “Nondiabetic
patients who developed dementia had a mean blood glucose level of 115mg/dl in
the preceding 5 years compared with 100mg/dl in similar patients who did not
have dementia. According to Dr. Crane, “the higher levels were associated with
almost a 20% [18% actually] increase in the hazard for dementia.”

This
piece by Paula Span in The
New York Times has another quote from Dr. Crane: “We found a steadily
increasing risk associated with ever-higher blood glucose levels, even in
people who didn’t have diabetes. There’s not threshold, no place where the risk
doesn’t go up any further or down any further.” The association with dementia
kept climbing with higher blood sugar levels and, at the other end of the
spectrum, continued to decrease with lover levels. He said that this held true
even at glucose levels considered normal, she said.

Another recent
article from MedPageToday
ties blood sugar (A1c) levels to cognitive function NOW, not to the far-off
future risk of dementia. The group studied was a population of non-diabetics, aged 50 and up, with
BMIs between 25 and 30. Their mean A1c was 5.8%, with a range from 4.3% to
6.5%. The researchers found that “each of the three cognition parameters
evaluated was significantly associated with A1c levels…”

The article, titled “Blood Sugar Tied
to Cognitive Function,” appeared in The
Gupta Guide, Sanjay Gupta, MD, Editor, and was reviewed by staff of the
Perlman School of Medicine at the University of Pennsylvania. The researchers
“added that ‘lifestyle strategies’ to achieve strict glucose control could
prevent age-related cognitive decline, even in individuals with A1c levels
currently considered normal…”

So, what’s the takeaway?What does it mean to change “how we think
about thresholds, how we think about what is normal, what is abnormal”? Well, well-designed
prospective controlled trials are needed to prove causation, but the association
of progressively higher and lower blood glucose with cognitive function, and
ultimately dementia, even at so-called “normal” and “nondiabetic” blood sugar
levels is undeniably true.

What is considered “normal”? And what
is “prediabetic”? From 1979 to 1997 the threshold for type 2 was two consecutive
visits with a fasting blood glucose of ≥140mg/dl. In 1997, ≥126mg/dl became the
threshold for diabetes. In 2010 the ADA added A1c standards, with an A1c of 6.5%
for diabetes (with a “treatment goal” of 7.0%!), and an A1Cs of 5.7--6.4% regarded
as “pre-diabetic”. Some physicians, notably Richard K. Bernstein, consider 5.8%
to be a full-blown type 2 diabetic. Another, Dr. Ralph DeFronzo, in his Banting
lecture at the 2008 ADA convention, said that “By both pathophysiological
and clinical standpoints, these pre-diabetic individuals with IGT should be
considered to have type 2 diabetes.”

IGT, or Impaired Glucose
Tolerance, is defined as a fasting Oral Glucose Tolerance Test result of
>140 at 2 hours. Statistically, you are 7-10 years away from diabetes and
your heart disease risk is already rising. To test your glucose tolerance,
follow the directions here: http://www.phlaunt.com/diabetes/14046889.php. But if there are no
thresholds for an increased risk of dementia, shouldn’t we all adopt
“‘lifestyle strategies’ to achieve strict glucose control” and thus potentially
“prevent age-related cognitive decline, even in those individuals with A1c
levels currently considered normal…”?

Wednesday, November 20, 2013

I
hope I have made it clear how absolutely thrilled I am by the ADA’s new Position Paper
titled “Nutrition Therapy Recommendations for the Management of Adults with
Diabetes.” It proclaims that “there is not a ‘one-size-fits-all’ eating pattern
for individuals with diabetes.” Importantly, the ADA declares “it was written
at the request of the ADA Executive Committee, which has approved the final
document.” The committee was comprised almost entirely of MSs, MPHs and PhDs
who are all also RDs and/or CDEs. Please take note of this important fact.

However,
we do not live in a perfect world, and there is only so much one committee can
do to turn the Titanic. This is an apt metaphor because we who have adopted a Western Diet
are all in the same boat. We are going to die from one of the diseases of
Western Civilization if we stay on our present course, i.e., if we continue to
eat the Standard American Diet (SAD) that we have been told to eat ever since
the diet/heart hypothesis was first promulgated in the 1950s.

Think
back - Ancel Keys made the cover of Time
magazine in January 1961 and joined
the board of the American Heart Association. In 1977, George McGovern’s Senate
Select Committee’s staff produced Dietary Goals of the United States. To say that both of these individuals were misguided
would be an understatement of, well, Titanic proportions. They will be remembered
as the principal enablers of the corrupt consortium of agribusiness, big
pharma, and self-serving, so-called “scientists” in the professional
organizations and government agencies who continue to perpetuate this mess
today.

Today,
the ADA committee’s changes represent just one voice in the ADA, on the nutrition
therapy side. Their goal, it seems to me, was increased flexibility to help
patients by “individualizing” the therapeutic approach. I think it was a
brilliant and a practical ‘workaround’ for the proscription on low-carb diets in
previous iterations: low-carb nutrition therapy was first deemed “safe” for one
year in 2008 and then more recently, for two years. Now, the time limit has
been eliminated. A low carb “eating pattern” is now perfectly okay to use
indefinitely. It is now at full par with others. There are no limitations.

So,
with that as preface, what outcomes can be expected? What goals do we set our
sights on achieving? How aspirational can we afford to be without seeming to be
unreasonable? Of course, I know
what is possible, but my n = 1 experience is purely anecdotal. What I am more
interested in seeing is what the ADA
thinks may be possible. What goals do they
set for glycemic control, and blood pressure and lipid improvement? The answer,
sadly, is abysmal. But don’t blame this committee. That was, as it should be,
beyond the scope and purview of their recommendations. Who then?

Answer: the ADA’s doctors. The goals the ADA hopes to
achieve for the management of adults with diabetes are as follows:

1.Attain
individualized glycemic, blood pressure, and lipid goals. General recommended goals
from the ADA for these markers are as follows*:

·A1C < 7%

·Blood pressure
< 140/80mmHg

·LDL cholesterol
< 100 mg/dl

·Triglycerides
< 150 mg/dl

·HDL > 40mg/dl
for men; > 50mg/dl for women

2.Achieve and
maintain body weight goals

3.Delay or prevent
complications of diabetes

*
A1C, blood pressure and cholesterol goals may need to be adjusted for the
individual based on age, duration of diabetes, health history, and other
present health conditions. Further recommendations for individualization of
goals can be found in the ADA Standards of Medical
Care in Diabetes (emphasis mine). This asterisk is by way of saying that
doctors may find it necessary to set less
ambitious goals (gasp!) than the already lax goals they have specified above. This is truly shocking.

So,
in case you have not divined where I’m coming from, it is the ADA’s medical doctors who set these goal and who
are not yet “up to speed.” Or, continuing the Titanic metaphor, as the mighty
ship of state (our health) continues to sink, “the band [the medical doctors]
plays on.” The RDs and CDEs “rearrange the
deck chairs” in issuing new nutrition therapy recommendations – but will this
make a difference or will it just be a futile exercise as our health continues
to sink? We’ll have to wait and see if the doctors at the ADA come around. Or,
even if not, if more patients
will do as David
Letterman has done and aspire to
higher goals to control their diabetes (and blood pressure and blood
lipids),”through diet, mostly.”

If you do work to
control your type 2 diabetes “through diet, mostly,” you can reasonably expect
to “achieve and maintain body weight goals” and “delay or prevent complication
of diabetes.” And you can achieve splendid lipids! As I am always crowing, I
have now lost 140 pounds, my most recent blood pressure was 110/70 (with meds),
and my A1c 5.7%. My latest Total Cholesterol was 217, LDL 122, HDL 85 and TRIG
49. In a separate test my LDL particles were Pattern A (large buoyant). I have
achieved and maintain this with a Very Low Carb WOE: 75% fat, 20% protein and
5% carbohydrate. The triglycerides are particularly influenced by carb in the
diet. This puts my Trig/HDL ratio at a stellar 0.57, indicating a very low risk of CVD. Does you doc do
that ratio for you? If not, look at your own #’s and do the interpretation yourself!

Saturday, November 16, 2013

Why,
indeed! When my doctor of 21 years died last year (the one I eulogized here), his
practice was sold and my medical records transferred to a nearby
internist/cardiologist who used to ‘cover’ for him. At my first appointment,
after the physical, the doctor asked me what he could do for me. I said I would
like to be seen 3 or 4 times a year, to which he replied, to my surprise, that it
didn’t seem necessary. True, I played my hand first, and he didn’t protest too much at my request to be seen that
frequently, but I’m sure he would have settled for less.

What
did this tell me? It told me that from his review of my file, and the physical
examination, that I was a fairly “healthy specimen” compared to his patient
base. I think his view of me was also influenced by my comment that I thought
my previous doctor, of whom I was very fond – he saved my life, I used to tell
him – had perhaps “milked the system” to help “pay the rent.” But I say this
about others too, like my auto mechanic: I know
I am helping him make his boat payments.

What
this also told me was that my desire to be seen 3 or 4 times a year was being driven
by my desire – that it was not
“medically necessary.” Of course, my desire is in no small part influenced by
the fact that I am on Medicare and I have good supplemental coverage. The
result is that, since my doctor accepts Medicare (and must accept the Medicare
allowed amount as “full payment,” and my supplemental pays the remaining 20% of
what Medicare allows, I have absolutely no co-pays and a very low annual
deductible. So, since I have “no skin in the game,” I can see a doctor as often
as I want without any financial
outlay (beyond the annual deductible). I think this is a lousy way to pay for
medical care, but it is what it is.

My
desire to be seen 3 or 4 times a year also gave me some insight into what
motivates me to want to. Now, no offense intended, doc (I think he reads the
column sometimes, and certainly will read one titled “Why Go to the Doctor”);
but, I don’t go to see him for his personality. Although his is great; he is
always positive, conversational, jaunty, indeed, almost bubbly. And,
interestingly, besides being board certified in his specialties, he holds a PhD
– a Doctor of Philosophy. How cool is that! But, on the specific treatment
modality for type 2 diabetes that I follow, nutritional therapy, I bet I could hold
my own – no, I daresay, I would whoop him handily on any “certification”
examination.

But
that’s all beside the point. In areas where I have no expertise at all, e.g.,
the medical aspects of diagnosis and treatment and etiology, pathophysiology
and therapeutic interventions for the diseases of Western Civilization, there
is of course no contest. So, one could
say that is good enough reason to go to the doctor. And it is one of the reasons I go to see mine. But, as I said, my doctor
(and I) see me as being “healthy,” for the most part. So, I don’t have to go to
the doctor 3 or 4 times a year to monitor that. What other reason(s), then, do
I have for more than, say, an annual or semi-annual visit?

The
answer, my faithful readers, is to monitor the metrics that I use to
track my diabetic health. Note the emphasis that I put on “that I use.” That
is because the metrics that I use are very
different from the ones my doctor uses. In fact, my metrics differ from virtually all
doctors who follow the government’s and the medical association’s and the
insurance agency’s guidelines for the management of type 2 diabetes. I don’t
want to get into the reason(s) for
those differences here – I tend to go off on a rant when I do. I’ll explain
more fully in the next column.I just
want to point out and stress that if you
do the same, that is, rely on the standards that your doctor uses, you do so at great risk to your health.
I’m sorry, doc, but that’s the truth, folks.

I
have written on this subject before, and will again, as I said. It could become
my mantra. And it certainly deserves articulation and recapitulation (as in themusical
sonata form where the exposition is repeated in an altered form). Understanding
this point is crucial to the type 2 diabetic who is taking responsibility for
his or her own healthcare and has chosen to do it “through diet…mostly,” in the
words of David Letterman in his
recent conversation on TV with Tom Hanks.

So, to repeat, if you leave the
evaluation of the measurement of your health to your doctor, most of
whom will rely almost entirely on the standards which they must follow to
assure that both they and you get covered by your insurance, you will, in my
opinion, be poorly served. That’s a
bit strong, but that’s the truth.

Bottom line: the main reason I go to the doctor is for a lab
report. And until I have him trained (sorry, Doc) in what I am interested in
knowing each and every time I go (and which my insurance will cover), I may have to ask for what I would like to have
tested. Of course, his office weighs me and takes my blood pressure, as I do at
home. I also test my fasting blood glucose daily for discipline and as a
reminder and a “check.” It’s the other blood tests that I want: the lipid
panel, the A1c, the C-reactive protein, and once a year the thyroid tests (free
T3, free T4 and reverse T3) and kidney function tests (creatinine).

Last
week a copy of my most recent tests arrived in the mail. My doctor is good about
that; I don’t have to request it. And the lab report is accompanied by a
modified form letter too. That’s nice. My blood pressure, by the way, was
110/70 (on meds). The lab test results: Total Cholesterol = 217; LDL = 122; HDL
= 85; triglycerides = 49; A1c = 5.7. My fasting blood glucose, though, was 109mg/dl
(!). I don’t know how that happened. It was 89mg/dl when I left home three
hours earlier.

Wednesday, November 13, 2013

On the David Letterman show recently,
57-year old Tom Hanks blurted out that his doctor had told him that after 20
years of high-normal blood sugars, “You’ve graduated. You’ve got type 2
diabetes, young man.” And all the coverage the next day was about how Hanks had
“performed an important role in raising awareness.” In the medical news, as in this piece,
“The Tom Hanks Effect: Diabetes Diagnosis Great for Awareness,” in M­­edscape Medical News, all I heard was
banal generalities about how a “regular guy,” who “doesn’t appear to lead an
unhealthy lifestyle,” can develop diabetes. And that “Diabetes is a very
treatable disease with good guidelines for effective treatment.” Boy, don’t get
me started on those “good guidelines.”

Nobody…I mean nobody
covered the most important utterance in the Letterman interview. It was
Letterman’s response to, “It’s
controllable…” to which Letterman added,
“…through diet, mostly.” Letterman then said that, “I
suffer from high blood sugar – had to go on a special diet myself.” Now, I’m
not a fan of Letterman, but he got it right, and nobody covered it. It’s true, Hanks is the news, and Hanks
did smother what Dave said with his funny rejoinder about getting back to his
high school weight. But his doctor had said, if he did, “he would essentially
be healthy and would not have
type 2 diabetes.

In a BBC interview, Hanks said that
he “gets regular exercise, eats right, takes certain medications, and, so far,
feels fine.” It sounds to me like he’s making the same mistake as Paula
Deen, except that she concealed her diagnosis until she had lined up a
pharmaceutical endorsement. They’re both leaving the control of their diabetes
health care in the hands of medical practitioners.Tom Hanks (and Paula Deen) should listen to
David Letterman: type 2 diabetes is “controllable…through diet, mostly.”

But I don’t think either of them will
listen to Dave, or me either. If Hanks had high blood sugars for 20 years and
hadn’t figured out what to do about it in that time, I don’t expect he will
now. Of course, I was in a similar – actually, identical situation for the
first 16 years after my type 2 diagnosis in 1986. So if I put myself in
Hanks’s shoes, I can be sympathetic. But I know
better now, and that’s why I work hard to try to persuade others not to follow
in my footsteps. If you are
pre-diabetic, you don’t have to develop full-blown type 2 diabetes. And
if you do, you can control it “…through diet, mostly.

I know I’m “beating a dead horse.” I
persist because I know it’s hard not to, by default, leave your health care in
the hands of your doctor. Doctor knows best and what is best for us,
presumably. Unfortunately, though, that’s not always true. They are human and
fallible. They know that, but they also know that, in order to gain and hold
your trust, they must preserve and maintain the appearance of omniscience.

They are constrained by a multitude
of factors: most were trained in the era of Ancel Keys’s diet/heart hypothesis
in which they were taught that saturated fat and dietary cholesterol were
killer foods. How can they now do a 180 degree turn and tell you that saturated
fat is good for you and that “cholesterol
in the diet
doesn't matter at all unless you happen to be a chicken or a rabbit,” in
the words of Keys himself later in life. And virtually no MDs have training in
nutrition.

They are also constrained by the
standards of practice of their medical specialty. It takes a long time for
research findings to influence clinical practice through updated guidelines.
Not to follow those standards would risk professional sanction and possible
loss of licensure. They are also constrained by the reimbursement rules of
Medicare and the insurance companies; they are constrained by limited time with
patients and limited time for continuing education. And, sadly, they and their
medical associations are so influenced by the big pharmaceutical companies that
conflicts of interest are inevitable. So
it’s
tough to be a doctor these days, but from the patient’s point of view, there’s
a workaround: self-care also known as patient-centered care.

If type 2 diabetes iscontrollable through diet, mostly,
Tom Hanks can do as David Letterman does and “go on a special diet” himself.
But it sounds to me like he doesn’t want to. “Hey,yougotta live,youknow?” Hanks has tweeted.
He’s decided he’s going to just “eat right,” exercise and take some meds. If he
follows this course, I don’t have to tell my readers that his disease will be
progressive, just as it was for the last 20 years that he followed his doctor’s
advice. And look where that got him: he “graduated.”

What does he expect? To be
congratulated? Wake up, Tom. Take responsibility for your own health. Take
charge of your own nutrition. Stop being in denial. You’re carbohydrate
intolerant, Tom. For whatever reason, including genetic predisposition, or body
type if you like, or past eating patterns. Don’t act like a victim. Show some
character. Show me some grit, Tom.Show
the world that you can be a positive role model. Show us you’re a good
man, Tom, like James Francis Ryan…

Saturday, November 9, 2013

Please
excuse me if once in a while I tear into a rant. I get frustrated and then very
cynical with some of the things I read. I also know that, individually, I have
so little power to influence outcomes beyond my own…and if I’m lucky, a few
others. But I still have to get some things off my chest. I could throw the
print copy out, but the content would still be swirling around in my head. So,
the only thing for me to do is to write about it. What set me off this time was
a piece that appeared in The Lancet
last month, “Funding: Global Alliance for Chronic Diseases tackles
diabetes.”

Here’s
what the BBSRC science writer Arran Frood said: “To meet the challenge in
emerging economies, the Global Alliance for Chronic Diseases (GACD) has
launched a call for research proposals to prevent and treat type 2 diabetes.
The GACD is an alliance of some of the world’s biggest publicly funded research
organizations, ranging from the UK’s Medical Research Council to China’s
Ministr­­y of Health and the European Commission.” Okay, that’s benign enough;
it’s an employment program for government scientists, a kind of job security.
Here’s what set me off:

“Refreshingly,
GACD members have realized that the science of type 2 diabetes is well
understood; this is no high-spending, high-tech genomics initiative but a
strict focus on implementation of existing policies, present knowledge, and
proven interventions.” It is reading arrogant bull$#%& like this, I think,
that gave me high blood pressure. Of course, it could also be related to my
weight, hehe, (because when I lost 140 pounds, my BP went from 130/90 to 110/70
on the same meds).

So,
these government bureaucrats, who know all about type 2 diabetes, are going to
disseminate their message to “low-income and middle-income countries, such as
China, India, and South Africa where the biggest emerging problems are to be
found, but where success might pay the highest dividends.” That’s just great!!!
The “developed” world, where this type 2 diabetes problem arose as a result of
“developments” in the growing, processing, manufacture and marketing of the
very foods that have made us sick, is going to spread the word about fixing the
problem, which is our Western Diet. Sell the problem and then sell the
solution!

Boy,
that’s irony for you, but obviously Mr. Frood doesn’t see it that way. He’s
refreshed. The GACD is going to “strict(ly) focus on (the) implementation of
existing policies, present knowledge, and proven interventions.” It doesn’t
occur to him that existing policies and present knowledge have not led to proven interventions.
They have produced the growing and out-of-control epidemic of not only type 2
diabetes, but obesity (an outcome,
not a cause of T2DM), dyslipidemia (characterized by low HDL, high
triglycerides, and Pattern ‘B’ LDL particles), and hypertension, collectively
known as the Metabolic Syndrome.

Okay,
Ivory Tower Dictocrats live in a special world – a world in which a primary
duty is to “call for research proposals” from other “publically funded research
organizations.” They are isolated from the real people-populated world in which
we mere mortals spread the word about the most effective intervention “to
prevent and treat type 2 diabetes” - Eat Real Food.” Now that would
be “refreshing.” ­­­­­But where’s the money? No drugs to market. No processed
foods to manufacture and sell. Simply small scale farming – just like they do now in
low-income and middle-income countries like China, India and South Africa!

So,
the best thing we “developed” countries can do is stay the hell out of the
management of type 2 diabetes in the underdeveloped and developing world until we get the message right.
I’m not hopeful, though. This is not likely to happen so long as the
Agribusiness lobby remains so thoroughly insinuated in the interstitial tissue
of our nation’s and the world’s advisory and regulatory bodies. I do not see an
end to this pernicious and insidious influence soon.

Meanwhile,
diabetes experts from all over the world met in Barcelona last month for the
annual meeting of the European Association for the Study of Diabetes (EASD).
They listened, I’m sure, to riveting presentations, and maybe got in a round of
golf. Among the reports, chronicled in Diabetes
in Controlhere, was a
research paper titled, “Big breakfast rich in protein improved glycaemic
control and satiety feeling in adults with type 2 diabetes mellitus.” I wonder
how much the taxpayer of some nation paid for that earth shattering news. I
really shouldn’t knock it, though. It’s the right message, and yet so many
clinicians and dietitians still don’t know this. For diet-controlled diabetics
like me, this is Nutrition 101, 1st day of class stuff.

My
favorite news flash, though, came from another Diabetes in Control item, here:
“Afternoon Napping Tied to Increased Risk for Diabetes.” It begins, “Since
afternoon napping is very common in China, Fang et. al. conducted a study to
determine if the duration of a person’s nap affected their risk for developing
diabetes or an impaired fasting blood glucose (IFG).” Their conclusion:
“Napping duration was associated
in a dose-dependent manner with IFG and DM” (emphasis mine). And “This finding suggests that longer nap duration may
represent a novel risk factor for DM and higher blood glucose levels.”

Okay, but association
is not causation. Perhaps the Chinese scientists will now apply for a grant to
undertake a randomized controlled trial (RCT) to determine if the outcome
observed by Fang et. al. can be attributed causally to the blood glucose crash
of some of the 27,009 participants a few hours after eating a bowl of
overcooked white rice. Maybe they’ll “discover” insulin resistance (IR). It
will certainly keep the scientists busy interpreting and reporting the results
for publication. Whew!

Wednesday, November 6, 2013

In a commissioned,
peer-reviewed and foot-noted
“Observations” column published October 22, 2013, in the
prestigious BMJ (British Medical
Journal), interventional cardiologist
Aseem Malhotra presented this stunning conclusion: “It is time to bust the myth
of the role of saturated fat in heart disease and wind back the harms of
dietary advice that has contributed to obesity.” The ground shook and a tsunami
rolled around the world. Ripples were even felt in the mainstream.

Dr. Malhotra reminds us that,
“Saturated fat has been demonized ever since Ancel Keys’s landmark ‘seven
countries’ study in 1970. This concluded that a correlation existed between the
incidence of coronary heart disease and total cholesterol concentrations, which
then correlated with the proportion of energy provided by saturated fat. But
correlation is not causation; and Keys
cherry-picked his data. Nevertheless, we were advised to cut fat intake to
30% of total energy and saturated fat to 10%.” That was and is a core
recommendation incorporated into the “Dietary Guidelines for Americans” from its
inception in 1980 to this day.

“The mantra that saturated
fat must be removed to reduce the risk of cardiovascular disease has dominated
dietary advice and guidelines for almost four decades,” Dr. Malhotra continues.
“Yet scientific evidence shows that this advice has, paradoxically, increased
our cardiovascular risks. Furthermore, the government’s obsession with levels
of total cholesterol, which has led to the overmedication of millions of people
with statins, has diverted our attention from the more egregious risk factor of
atherogenic dyslipidaemia.” Translation: Low HDL and high triglycerides, plus
small-dense LDL lipoprotein particles (“Pattern B” LDL) accompanied by systemic
inflammation, all of which are potent cardiovascular disease risk factors.

Dr. Malhotra covers some
familiar ground as well: “Scientists universally accept that trans fats – found in many fast foods, bakery products and
margarines – increase the risk of cardiovascular disease through inflammatory
processes.” And he nicely clarifies a point: “Consumption of processed meats,
but not red meat, has been associated with coronary heart disease and diabetes
mellitus, which may be explained by nitrates and sodium as preservatives.” But
he comes back to saturated fat with this: “Indeed, recent prospective cohort
studies have not supported any significant association between saturated fat
intake and cardiovascular risk. Instead, saturated fat has been found to be
protective.” See his citation here.

“In previous generations
cardiovascular disease existed largely in isolation,” he says. “Now two thirds
of people admitted to hospital with a diagnosis of acute myocardial infarction
really have metabolic syndrome – but 75% of these patients have
completely normal total cholesterol concentrations. Maybe this is because total
cholesterol isn’t really the problem,”
he quips (emphasis mine). Metabolic Syndrome is “the cluster of hypertension,
dysglycaemia, raised triglycerides, low HDL cholesterol, and increased waist
circumference.” Do these sound familiar? Does it apply to you? Does it worry
you, yet?

Dr. Malhotra reminds us that,
“The notoriety of fat is based on its higher energy content per gram in
comparison with protein and carbohydrate,” but he cites Richard Feinman and
Eugene Fine’s work on “metabolic advantage” to show that “different diet
compositions showed that the body did not metabolize different macronutrients
in the same way.” “The ‘calorie is not a calorie’ theory has been further
substantiated,” he adds, “by a recent JAMA study showing that a low fat diet resulted in the greatest decrease in
energy expenditure, an unhealthy lipid pattern, and increased insulin
resistance in comparison with a low carbohydrate and low glycaemic index diet.”
This is beginning to sound like a broken record.

So, will this message
resonate? Were there aftershocks? Sure, I was startled awake one morning with a
‘teaser’ on an early morning TV news program. Later, the Diet Doctor, Andreas
Eenfeldt, featured it here. The BBC Health News featured it here,
and they also had a morning show video segment. The latimes.com had this piece by Melissa Healy. And early tremors were
registered at paleodietlifestyle.com here.Maybe
it will resonate this time, if enough people hear it, over and over…

Finally, Dr. Malhotra comes at it from a different angle: “When you take
the fat out (of food), the food tastes worse.” “The food industry compensated
by replacing saturated fat with added sugar. The scientific evidence is
mounting that sugar is a possible independent risk factor for the metabolic
syndrome.” He’s now come full circle. “Saturated Fat is not the major issue,”
the title of the piece shouts. The sub-title, “Let’s bust the myth of its role
in heart disease…” Bravo! This stake to the heart will help. But ‘SFAs = bad’
is an undead concept that will persist to eat away at our health, like a zombie
apocalypse.

Saturday, November 2, 2013

Having
just sung the praises of the American Diabetes
Association’s new Position Paper on nutrition therapy guidelines,
it’s painful for me to have to criticize their unbending adherence to the
“conventional wisdom” with respect to saturated fatty acids (SFAs), aka
saturated fats. They dodge the issue. Instead of saying “the evidence is
inconclusive…so goals should be individualized” (as they did with macronutrient
distribution), they say: “Due to a lack of research in this area (?!!), people
with diabetes should follow the guidelines for the general population,” from
the Dietary Guidelines for Americans. What a cop-out.

The
ADA deserves to be cut a little slack, though, for not taking on too many
giants at once. For the ADA to have officially said, “It is the position of the
American Diabetes Association (ADA) that there is not a ‘one-size-fits-all’
eating pattern for individuals with diabetes,” that’s enough for me, for now. All who have suffered the angst of
having the n=1 experience of losing weight easily, without hunger or cravings, and having
their Metabolic Syndrome disappear on
a Very Low Carb (VLC) dietary, have been frustrated. And we did it all without
approbation (and occasional outright hostility) from the “dietary authorities,”
We can applaud the ADA now as it is the first major organization in the U.S.A.
to break with that outdated idea.

For
this diabetic, as my weight dropped, so did my blood pressure, from 130/90 to
110/70 (on the same meds). And while my LDL cholesterol particle number didn’t
go down, the particles changed from small-dense (“Pattern B”) to large-buoyant
(“Pattern A”), making it less likely that they could get stuck in any erosion
in the endothelial layer of my arteries. Such erosion, by the way, is caused by
inflammation, but on this VLC Way of Eating, my C-Reactive Protein test, a
blood marker for systematic inflammation, is often below 1.0, the level
generally considered “ideal” for cardiovascular risk.

Serum
cholesterol attempts to repair the small-dense LDL trapped in the eroded
arteries, by creating plaque. That’s why cholesterol is blamed for plaque, but
it’s like blaming the fireman for putting out the fire. Statins are thought to
work by stabilizing plaque. Low systemic inflammation, large-buoyant LDL
particles, and high HDL to carry excess LDL particles away from the heart and
back to the liver, prevents plaque formation. It is a much better way to
mediate CVD risk.

The ADA now recognizes that Low Carb
eating is “healthful,” but they still
tow the line of the AHA, AMA, HHS and the USDA with respect to which fats are
healthful. (If you reduce carbs in your diet, those calories will be replaced
primarily with fats, so it is important that you choose healthy fats.) The
dietary authorities all suggest that MUFAs (monounsaturated fats like olive
oil) are healthful, and all now admit trans fats (artificially saturated vegetable oils) are deadly; but that naturally saturated animal fats, and the dietary cholesterol
that accompanies them, are unhealthful. And that PUFAs (highly processed polyunsaturated fats
found in vegetable oils like corn and soy bean oil) are healthful!!!

They unfortunately still lump naturally
saturated fats found in animal products with the artificially saturated trans fats manufactured from highly processed vegetable
oils. This conflation is an egregious and malevolent perfidy perpetrated and
perpetuated by industry influence, specifically the Agribusiness lobby which is
so thoroughly insinuated in the interstitial tissue of our nation’s advisory
and regulatory bodies. It is a bogus association. They are totally dissimilar in their
structure and effect on the body’s cells.

The “authorities” also fail to recognize the dangers from the disproportionate
amount of inflammatory Omega 6s we are eating (relative to Omega 3s) since
vegetable oil has become so prominent in our diet. Vegetable oils are
everywhere, particularly if you eat restaurant meals, processed foods or commercial
mayonnaise and salad dressings. It is
very difficult to correct the balance of Omega 6s to Omega 3s without
avoiding as completely as you can all vegetable oils (high in Omega 6s).

The
ADA’s position on SFAs leads them inexorably to advocating one “eating pattern”
in particular, the Mediterranean style. That’s fine if
you’re not diabetic or
pre-diabetic. If you can keep
a healthy metabolism eating “abundant plant food (fruits, vegetables, breads,
other forms of cereals, beans, nuts and seeds)”, good for you. I’m jealous. (Note to
the ADA: Diabetics can’t.) But for
those who can, by all means eat “fruit as the typical daily dessert and
concentrated sugars and honey consumed only for special occasions,” and “olive
oil as the principal source of daily lipids, dairy products (mainly cheese and
yoghurt) consumed in low to moderate amounts,” etc. Of course, it allows only
very limited amounts of red meat and eggs and thus is definitely skewed away
from dietary cholesterol and saturated fats – all misguided, unnecessary, and in fact, unwise IMHO – especially
for the metabolically compromised, as
we diabetics all are.

I do not blame this ADA committee, though. Rather, I praise the
courageous stand of this committee comprised of PhDs and MPHs, all of them RDs
and CDEs. They prepared this groundbreaking report, and the ADA Executive
Committee commissioned and approved the final document. They deserve our acclamation
for having made the turn in accepting – no, verily promoting and supporting any and all “healthful
eating patterns, emphasizing a variety of nutrient dense foods in appropriate
portion sizes, in order to improve overall health…” And even though
they incline towards the “Mediterranean style” for reasons relating to what I
regard as a vestigial bow to orthodoxy, they now explicitly and unambiguously
include the low-carb diet as a healthful Way of Eating. Wunderbar! What will be the next canon of orthodoxy to fall? Will it be saturated
fat? See the next column.

About Me

I was diagnosed a Type 2 diabetic in 1986. I started a Very Low Carb diet (Atkins Induction) in 2002 to lose weight. I didn’t realize at the time that it would put my diabetes in clinical remission, or that I would be able to give up almost all of my oral diabetes meds. I also didn’t understand that, as I lost weight and continued to eat Very Low Carb, my blood lipids would dramatically improve (doubling my HDL and cutting my triglycerides by 2/3rds) and that my blood pressure would drop from 130/90 to 110/70 on the same meds.
Over the years I changed from Atkins to the Bernstein Diet (designed for diabetics) and, altogether lost 170 pounds. I later regained some and then lost some. As long as I eat Very Low Carb, I am not hungry and I have lots of energy. And I no longer have any of the indications of Metabolic Syndrome.
My goal, as long as I have excess body fat, is to remain continuously in a ketogenic state, both for blood glucose regulation and continued weight loss. I expect that this regimen will continue to provide the benefits of reduced systemic inflammation, improved blood lipids and lower blood pressure as well.